critical“Checks of care records had failed to identify staff were not always measuring and recording urine output as instructed within people's catheter risk assessments.”
moderate“Risk assessments were not being reviewed regularly. A medication risk assessment had not been reviewed for over 25 months.”
moderate“Some care plans and risk assessments lacked detailed guidance to inform staff how to support people safely.”
medication management
3 findings
moderate“Some care records did not clearly record when non-prescribed topical creams had been applied or contained guidance for staff to ensure they knew when and how often to apply the creams.”
critical
“one person did not receive their prescribed, Morphine Sulphate for two consecutive days”
critical“person's medication risk assessment failed to include their allergy to penicillin, placing them at risk of potential harm”
governance
2 findings
critical“The provider remained in breach of regulation 17. The provider had failed to fully meet the warning notice we issued at the last inspection.”
critical“Systems were not established or operated effectively to assess, monitor and improve the quality and safety of the service.”
record keeping
2 findings
critical“A person's allergy was still not documented on their medication risk assessment despite this being raised at our last inspection.”
critical“one person's records stated the wrong name of their medical condition and did not include the symptoms staff needed to respond to in a medical emergency”
incident learning
2 findings
moderate“The management team had completed audits and looked at incidents, however there was no evidence that learning, or themes were taken from this to improve the quality of care provided.”
moderate“Lessons had not always been learnt and opportunities to make improvements had been missed.”
infection control
1 finding
moderate“provider had not completed risk assessments for people or staff that were more susceptible to the risk of infection during COVID-19”
missed or late visits
1 finding
moderate“provider did not have a robust system in place to monitor the time staff arrived and left people's homes, or to ensure people had received their planned care”
complaints handling
1 finding
moderate“complaints were not always managed, in line with the provider's policy. As, not all complainants received a written response”
person centred care
1 finding
moderate“Some people told us, they did not receive care at the time, they wished or by a staff member, of their preferred gender.”
end of life care
1 finding
minor“One person did not have a personalised end of life care plan in place, or guidance for staff to follow, as their health deteriorated.”
communication with families
1 finding
moderate“some people told us, they didn't feel listened to, as nothing changed in relation to their call times, consistency of staff and tasks not completed”